Another failure by a system "not fit for purpose"

THE husband of a woman who took her own life in Hydebank Wood has raised serious questions about whether the Northern Ireland prison system has the ability to deal with inmates that have complex mental health issues

Brian McKeown spoke to The Detail to respond to a new report by the Prisoner Ombudsman, who investigated his wife Frances’ death.

Mrs McKeown (23) was psychologically fragile, had a lengthy history of mental illness stretching back before her imprisonment and had threatened suicide many times. She took her own life in Hydebank on May 4 last year, five hours after Samuel Carson, 19, died by suicide in a neighbouring block after a lengthy campaign of bullying.

Key findings from the ombudsman’s report into Frances’s death, published today, echo those in investigations into other prison suicides here over the years, raising bigger questions about the ability of the prison system to get to grips with managing the emotional and psychological problems of the prisoners in its care.

This latest report found:

• Mrs McKeown was not seen by the prison psychiatrist for six months and the authorities also failed to request her previous GP and medical records.

• Despite an awareness of her mental health history – she was subjected to long periods in her cell because of repeated prison lock downs.

• The death of another male prisoner at Hydebank Wood Young Offenders centre resulted in her being locked up once again and may have influenced “her decision in other ways.”

• The systems in place failed to adequately monitor her medication properly.

As previously reported by The Detail, the investigation also sheds new light into incidents of bullying by other inmates that occurred after Frances witnessed a male prison officer kiss another female inmate.

Speaking to The Detail, Frances McKeown’s husband Brian says the report raises serious questions about the appropriateness of placing someone with Frances’ complex care needs in a prison regime.

FRANCES’ HISTORY

Frances, a mother of two, was found dead in the women’s section of Hydebank Prison, just hours after the death of prisoner, Samuel Carson, in another section of the prison.

In February The Detail revealed Frances’s long history of mental illness and repeated threats to take her own life.

The latest investigation report produced by the Prisoner Ombudsman, Pauline McCabe, states that despite a referral being made to the mental health team within a week of Frances entering prison, she was not seen by a member of the team until six weeks later and it was another five months before she was considered by Hydebank Wood’s Safer Custody Team.

The report states that Frances’ family believe she “drifted away” from them and stopped engaging with community health services when she was 18-years old. At 19 she met her husband and they had their first child. Following the birth of their second child and difficulties with their marriage, both children were taken into care.

Considering possible reasons for Frances’ death, one of the senior experts used by the Prisoner Ombudsman, Dr Seena Fazel a Consultant Forensic Psychiatrist, states: “On the basis of background history Ms McKeown had a number of risk factors that indicate an increased risk of suicide in custody. These include a history of recent suicidal thoughts and attempted suicide before custody… a current psychiatric diagnosis, and a history of reported sexual abuse.”

Prisoner Ombudsman Pauline McCabe /

The Ombudsman also stated that Frances had a number of recent stress factors including the fact that her two infant children were being fostered and their future custody arrangements were uncertain.

Dr Frazel concluded that: “These recent stressors and future anticipated problems in the background are part of any formulation about the reasons for her untimely death. It was also the case that, following a conversation with her solicitor, Frances apparently believed that she might receive a sentence of four to five years which had upset her as she was expecting one year.”

Frances wrote a suicide note which focused on her symptoms worsening and not being able to cope.

Her husband Brian McKeown believes the prison regime at Hydebank Wood wasn’t capable of dealing with the complex needs of his late wife.

He said: “We know now that Frances went for months without proper access to medically trained experts and even then they didn’t have access to her previous records. It’s only common sense that when you are dealing with a prisoner with Frances’ history, these things are going to be essential in understanding the type of prisoner you’re dealing with.

“I think when Frances was a remand prisoner she should have been bailed to a mental institution of some sort where she would have at least had access to adequate medical help, certainly more than she ever got in prison.”

THEJOURNAL

From April 2011 until she died, France kept a personal journal she titled: “Life as a Highbanker.” The journal provides personal insights into how Frances was feeling, her plans to take her own life and what life in prison was like for her. Excerpts from Frances’ journal are included throughout the ombudsman’s report. They include intimate details of Frances’ thoughts during her time in Hydebank Wood.

On April 24 2011 Frances wrote: “Because I suffer from mental health my time for thinking is my biggest problem, when I have too much time to think on my hands this is when my mood lowers severely and I become suicidal. My thoughts make my mind snap and I just can’t cope with it anymore so I self harm to try and stop it and block out the thinking. Sometimes I even go far enough to plan a new way to end it all just to stop my pain from thoughts.

“I have a long term goal in life and it isn’t to live. It is to die but it is not for a few years yet. It is something I have been contemplating and planning from I was 13 years old and now I know my plan of action down to the last detail.”

Speaking to The Detail, Mrs McCabe said the journal entries were an important part of helping her and her team build a picture of what Frances was going through. She said: "The diary entries reflect the fact that she was very troubled at times, especially when left alone in her cell, they really bring home the extent to which the voices in her head could control her and how she found it difficult to cope.

“But they do also show that there were good times, she valued her friendship with one inmate in particular and benefited from some of the therapeutic sessions within the prison. However, it clearly show show difficult things can get for someone with Frances’ complex needs in a custodial setting.”

INAPPROPRIATEBEHAVIOUR

On January 17 2011, Brian McKeown sent a letter to Hydebank Wood. He raised concerns around an incident Frances had confided in him whereby she had seen a prison officer kissing another inmate. He said he was afraid that she was going to “get beaten by the lady in question.”

Mr McKeown recalls that alarms bells instantly went off when he heard what had happened.

He said: “When she told me she had witnessed a prison officer kissing an inmate, I told her to report it immediately. Given Frances’ mental state I had concerns that similar things could be happening to her and that’s why I also felt I had to raise concerns.

“The report suggests that issues around bullying seem to stem from this incident and this undoubtedly would have had an impact on the mental well being of Frances.”

As revealed by The Detail in May this year, it was how senior staff at Hydebank handled this incident which led to the suspension of Hydebank governor, Gary Alcock. Click here to read the full story, as detailed in the Prisoner Ombudsman’s latest report, of the series of events that led to the governor’s suspension.

In the report Mrs McCabe states that as well as Mr McKeown’s concerns, she also received an anonymous letter from a “concerned staff member” at Hydebank who alleged that Frances had been bullied and threatened by other inmates.

She also states that during the course of the investigation it became evident that others believed that some inmates had treated Frances in a way that could be described as bullying. This was said to have occurred because inmates believed that Frances had told the security department at Hydebank that she had seen a male prison officer kissing a female inmate. Concerns were raised that Frances’ treatment by some prisoners might have contributed to her death.

Mrs McCabe concluded however that while the investigation did find evidence that Frances was treated in a way that could be described as bullying by some inmates, because of her already fragile mental health, it was unlikely that bullying by other inmates was a direct cause of her death.

As part of The Detail’s latest investigation we can also reveal that 16 claims have been brought against the Northern Ireland Prison Service by female inmates since 2004, including one alleging an incident of “a sexual nature”, according to figures released under Freedom of Information legislation. Click" here(Claims against prison service include on alleged “sexual incident”)":http://www.thedetail.tv/issues/151/frances-mckeown/claims-against-prison-service-include-one-alleged-sexual-incident to read the full story.

THELOCK UP – “TIME TO DIE”

Hydebank Wood Prison has been criticised for its use of lock ups

Elm House is one of the accommodation blocks for the male young offenders who share the same sites as the women’s prison. The Prisoner Ombudsman’s report outlines that at 17:00 on May 4 2011, Frances’ landing had been unlocked so the inmates could have their tea. However, within a few minutes an emergency alarm went off in Elm House and a ‘code blue’ was called over the prison tannoy.

Code blue means that there is a medical emergency to alert medical staff to the type of response required. There are a number of reasons why a code blue would be announced including when a casualty is unresponsive to voice or has a ligature.

As a result Frances and the others prisoners from her landing were locked up. Mrs McCabe outlines that at interview some inmates had said that when Frances knew that there were going to be locked up early she was angry commenting: “That’s another night I’m going to be locked up. I can’t be f***king bothered to be locked up again.”

Another inmate said that the last thing Frances said to her was “I can’t take anymore lock-ups.” One inmate who the report identifies as being particularly close to Frances said: “The week before she died we were playing football up in the fields and we had a great laugh. She was in good form. The night before she died she was singing and dancing in my cell. I don’t know whether it was a cry for help… I think there were far too many lock ups.”

The ‘code blue’ incident concerned the death of a young man in Elm House – Samuel Carson. Last week the Prisoner Ombudsman released her report on this death in custody. Click here to see The Detail’s coverage of the report.

During the evening of May 4 2011 Frances wrote in her journal: “There was a code blue tonight on the wee lads house Elm. Code blue is when someone has hung themselves and died, so we are locked all night. If these voices keep up there will be another code blue tonight. I already have my noose made and ready but I can’t do anything until the night staff do the alarms. Then I have one hour…I’ve got it planned and tonight is the night.”

At 19:25pm the officers left the landing and the grill to the landing was closed over. At 20:38 CCTV footage shows that following a head count check, the night custody officer could not see Frances in her room and did not receive a response from her, shortly afterwards an emergency unlock was carried out.

On entering Frances’ room she was found unresponsive with a ligature tied around her neck . The officer immediately cut the ligature and with the help of her colleague, manoeuvred Frances out onto the landing.

At 21:10pm CCTV shows a doctor and cardiac team arriving on the landing. At 21:17 the doctor pronounced Frances dead.

Frances’ husband still has concerns about her last few hours.

He said: “She had told me before that there was a considerable amount of lock downs and that she found it hard to cope, clearly the suicidal thoughts that Frances was having were eating her up during these periods. There’s nothing I can do now, but I would like to think that a situation like this would never be allowed to happen again.

“One thing that stood out for me from the report was that given Frances’ history, how was she allowed to have anything in her cell that could be used as a ligature."

In the report it states that Frances’ best friend in prison said that it was Frances’ intention to die after she left prison. Mrs McCabe said that this might suggest that Frances’ actual decision to die by suicide on the evening of May 4 2011 was only taken on that date. She stated that it was one possibility that the death of Samuel Carson which had resulted in her being locked up once again, may have “influenced “her decision in other ways.”

Mrs McCabe told The Detail that the prison service have taken steps to address the issue of code blues and lock downs. She said: "On the back of this death we spoke with the prisons service about this and it is now the case that if there is a code blue taking place in either of the two establishments then this will not led to an automatic lock down in the other.

“Inevitably in prison there will be periods were lock downs occur, but I believe lock downs are the enemy of the vulnerable and in particular for someone likes Frances with a personality disorder. We do regularly see evidence that when vulnerable prisoners have human contact and involved in purposeful, busy activities – this is the best way to care for them.”

Mrs McCabe also points out in her report that staffing arrangements over Christmas, Easter and other bank holidays resulted in longer lock downs and less access to purposeful activity and work for vulnerable prisoners.

MANAGEMENT OF MEDICATION

An autopsy found that Frances had taken the non-prescribed anti-depressant Trazadone. The clinical reviewer in the Prisoner Ombudsman’s report, Dr Malcolm VandenBurg, a specialist in General Medicine, states that Frances may have been using the drug for its sedation effect because she had difficulty sleeping:

He said: “Patients with a history of suicide-related events, or those exhibiting a significant degree of suicidal ideation prior to commencement of treatment with Trazadone are known to be at greater risk of suicidal thoughts or suicide attempts, and should receive monitoring during treatment.”

Dr VandenBurg also pointed out that Frances’ prescribed medicine was also subject to similar warning.

The report also highlights shortcomings around Frances’ Supporting Prisoner at Risk (SPAR) booklet. The booklets are used at times when staff deems an inmate as vulnerable to self harm and suicide. Its purpose is to provide increased observations and support for an inmate. The report found that contrary to Prison Service policy, there were occasions when Frances’ SPAR booklets did not move with her when she attended appointments off the landing.

The Prisoner Ombudsman found that while there was evidence of staff taking time to talk with Frances, no evidence was found that Frances’ SPARs were reviewed to establish whether there was a pattern to her self harming or whether there were triggers for episodes of low mood which should be considered as part of her care plan.

Mrs McCabe claims in her report that while these failures are not considered to have contributed to Frances’ death, she believes that “such failures in the future could increase the likelihood of a serious incident or tragedy.”

The South Eastern Health & Social Care say they have put in place a number of improvements in prison healthcare with regard to mental health provision in Hydebank Wood, including recruitment of additional healthcare staff. For full details on the other measures please click here.

The Trust continues to work to improve the provision of healthcare services to all prisoners across the three prison sites in Northern Ireland.

Brian McKeown says the prison watchdog’s report has only reiterated what he already knew; that Frances was failed by the system.

He said: “There’s no doubt more could have been for Frances during her time in Hydebank Prison, she didn’t get the help she needed, when she needed it most.

“The full findings of the report will probably take some time to properly sink in, but what it does flag up is that the situation in Hydebank is inadequate and I’m sure over the coming weeks once I’ve had a chance to digest it properly there’ll be a lot more things that I’ll want addressed.”